Wednesday, December 07, 2005

Parkinson’s

No, not the talk show host, not the disease, nor even the dirty joke about how old men in the old-folk’s home prefer old women with that disease, but this letter from the ST Forum today:

Dec 7, 2005Review doctors' working hours, for safety's sake

I refer to the article, 'Checks in place to manage stress, fatigue' (ST, Dec 2), which stated that pilots are not allowed to fly more than 100 hours in any 28 consecutive days. This is to ensure that they fly with full concentration and deliver passengers safely to their destinations.

I wish to relate this to the plight of doctors here. Not long ago, an article in Time magazine reported that in the United States, around 98,000 deaths each year are the result of medical errors. Could some of these errors be due to fatigue or poor concentration?

I have friends who are junior doctors. They tell me their workday typically starts at around 7am, when they prepare to do ward rounds, after which the rest of the day is spent mostly in the wards carrying out instructions given by senior doctors. Their day theoretically ends at 5pm, but they do not usually leave before 6pm.

And when they have night duty, they work continuously from 5pm till the next morning. Thereafter, they continue the morning's duties like in any other day. They are allowed to leave only when they have completed the tasks for that morning. Many a time, it can be as late as mid-afternoon. That means they would have worked non-stop for close to 24 hours. And these night duties can occur up to six times a month.

These junior doctors are always stationed in the hospital wards and if their concentration and competence are affected by fatigue, are we not placing patients at risk?

Are we so short of doctors? Or are the hospitals swamped with too many patients? As with passenger safety, when there are patients' lives at stake, it makes sense for doctors' working hours to be reviewed.

The cost of unsubsidised healthcare is so high and hence the subsidy so attractive, that people will continue to seek subsidised healthcare and stretch it to its capacity unless one or both of two things happens:

1. It becomes so dangerous or unpalatable that people would rather spend the extra money than to receive it.

2. A system is in place to deny people of subsidised healthcare, based on whatever criteria as the case may be (e.g. means testing).

It seems that the author of the letter is arguing that we should do something about doctors’ work hours before 1. becomes a reality (some would argue that it already is a reality), without implying that 2. is the solution.

I don’t think anyone is actually perpetuating the current system of night-calls which really means six or more 36-hour shifts per month just to torture junior doctors. A simple calculation will tell you that to have separate night-shift doctors will mean a doubling of manpower requirement if after-hours are to be fully-staffed, or a 50% increase if it is on half-staff.

The current manpower shortage simply does not allow that, even if we had the money to employ the staff. Or is it a distribution problem? Can we increase the manpower pool by luring GPs in the private sector to work as junior doctors for a five-figure salary? It might work, but that will drive healthcare costs up to an amount we are not willing to bear. Plus from Parkinson's Law, one can predict that people will continue to consume as much healthcare we can provide.

Something has to give.

I don't really wish to see 1. happen, so I guess I have to root for 2.

I'm not a fan of means testing as it stands though - it allows for a situation where a poor person may over-consume healthcare he does not need with impunity, while a rich person who needs it for a major illness can quickly become no-longer-rich from having to pay for it.

Even though this is theorectically a question of economics, as doctors we see this being played out so often you wonder if there is a fairer way of doing it.

24 Comments:

Interesting post. I'm going to have harsh words.

Well I would say that working 24 hours is no big deal. We used to do 60 hour calls (from Saturday morning to Monday evening) in certain postings in small departments. I remember operating with the registrar from Saturday morning all the way till Sunday afternoon and falling asleep on the operating table in the wee hours of Monday morning.

Many senior doctors told us that was "character building". I say it's crap.

We all know that the "shortage" of doctors can be made up if all the lazy fat consultants got out of their ivory towers and came down to do the "menial" work of the housemen. Eg writing blue letters for inter disciplinary referrals themselves, taking blood samples, writing discharge summaries, arranging for urgent CT scans etc.

And the excuse that they have to run clinics or operate are sometimes nonsense especially when you find the consultant reading newspapers sipping his coffee in the operating theatre tea room while his registrar and MO are doing the operation for him in the theatre.

We really need to have a better system to protect the working conditions of doctors in general.

But one of the problems I feel is that with the health care system, it is often too easy to trace back the problem to ONE individual eg a doctor or a nurse and pin the blame on them, thus indemnifying the "system".

More often than not, people would say it was because of that lousy stupid inexperienced greenhorn doctor that caused my mother's death. Nobody would ever think about the "system". And you can sue the bugger for negligience. What "system"?

Also if a doctor makes a mistake due to fatigue, at most ONE life is lost or terribly affected. Just ONE. For a single doctor to do harm to a few or many patients is simply unthinkable and frankly impossible. So in many cases, the anger comes from just ONE family. It isn't strong or scary enough to make the "system" sit up and notice.(of course unless it happens to be a very powerful or influential family)

Unlike pilots, if the surgeon falls asleep at the operating table and screws up totally. At most only ONE life is lost. Pilots can kill hundreds. That is where the TRUE difference lies. The pilot is paid and taken care of because he takes care of many. And hence the leverage is there.

Doctors? I think anyone who has read this would agree, doctors have no hope in hell for things to improve.

Actually, the system can be sued by naming the hospital as the defendant.

In the US, judges realise that error rates can be lowered if the hospitals were willing to put money into the system by having sufficient staff to do all the checks. But this is not done for economy reasons.

To counter this, they award huge sums to the plaintiff. The awards are not commisurate to the financial loss of the patient, but pegged to hurt the hospital. Punitive damages, as it were. Basically, if the cost of implementing a system to prevent the error that had occurred would be X million dollars, they would award a sum in excess of X million dollars.

The fundamental fact is that one doctor can only cause harm to ONE person at a time.

Pilots can kill hundreds. Even the Nicoll Highway disaster showed how systems can be reviewed, only if a major disaster occurred.

One patient's death in the hospital has never been termed a disaster by the media.

Maybe doctors should do something that harms hundreds? Eg maybe young tired houseman accidentally trips or presses some button that exposes the radiation core of some portable X-rayd machine or something?

It's just that it's happening "quietly" & in "bits & pieces" instead of like a dramatic plane crash, which is probably what made everyone sit up & take notice 40 - 50 years ago in the aviation industry.

Well, people are starting to sit up & take notice when it comes to medical errors in the USA, Australia, UK...about time for them to do so here too.

It is perhaps more likely that those juniors just didn't want to seem weak or useless, lest the senior doctors launch into a similar spiel about how they used to do 60 hour calls themselves. Proclaiming your tiredness 6 times a month is hardly the way to impress.

You wanna learn, then be prepared to slave. I know. I did. And now look at me! Although thank heavens for the little kindness that I was not interested in blood and gore and sick people. Come to think of it. I don't like hospitals at all and I just wonder why people can spend their lives working in such places.

I am quite perplex. How come doctors I know and saw in action are working their butts off but these two, yeah, I mean Angry and OZ are so free to blog.Beats me. Something is wrong in the system. You don't get senior pilots walking around the plane with a glass of champagne and chatting with the passengers do you?

It is perhaps more likely that those juniors just didn't want to seem weak or useless, lest the senior doctors launch into a similar spiel about how they used to do 60 hour calls themselves. Proclaiming your tiredness 6 times a month is hardly the way to impress.

I hope you were being sarcastic. "

Well it all depends on what your definition of stupid is.

On one hand it seems really smart not to complain about being tired 6 times a month, and impressing the bosses by looking real strong and all.

However when you make a mistake because you are too tired, eg giving an antibiotic that the patient was allergic too and subsequently getting into a nasty lawsuit. Well then are you going to tell yourself you were just being smart by impressing the bosses?

The point here is that I find doctors in general (including myself when I was a junior doctor) all too self centred. We always think of ourselves. How we get get promoted, get that raise, get that traineeship etc. And then when something goes wrong, we think about ourselves again. How we were too tired because of the many calls and that it should not have been this way etc etc.

Overall, we don't realise that this thinking is what makes doctors so easy to sweep aside. There is no unity among the ranks. One doctor who has to answer the complaint letter or lawsuit because he made a mistake when he was too tired post call will cry "Less calls, more rest for doctors"

His colleague who is the "Rambo of the department and blue eyed boy of the head of department" will cry "That guy is weak. If he can't deal with it, he shouldn't get his traineeship!"

See? That's the problem? Who is smart and who is stupid?

But at the end of the day I told myself to start thinking about others. In particular the patient. If I was a patient going into the OT to have an operation, would I like knowing the fact that my surgeon had not slept in over 48 hours?

I would be very worried frankly. And that is where I think the real definition of stupidity lies.

Should doctors who had not slept in 24 hours be treating patients at all?

Answer that question objectively and directly. No buts, no manpower explanations. Just answer logically whether that should be taking place.

"I am quite perplex. How come doctors I know and saw in action are working their butts off but these two, yeah, I mean Angry and OZ are so free to blog.Beats me. Something is wrong in the system. You don't get senior pilots walking around the plane with a glass of champagne and chatting with the passengers do you? "

Nothing wrong with the system. It's just that I have no patients and no business and no money :) Fair system isn't it? No complaints there.

And well maybe you haven't sat in first class? I haven't either. But what do pilots do in between flights?

I know my pilot friend has got pretty generous off-days. He can't fly more than a certain number of hours whether he wanted to.

All the more reason why to stay away from government hospitals if you need surgery.

Can go there to chat chat with the specialist for fun and second opinion but for the real cutting edge (pardon the pun) surgical techniques and skills, go private.

How to pay for it? Get medical cover early in life. Work hard, save money and start a private medical fund for family. Outperform the STII in fund returns.

Don't trust government hospitals and the overworked underpaid doctors and surgeons. Never have and never will.Better to die quick then getting cut halfway and the surgeon pass out and his junior sidekick takes over. Don't know the fallopian tube from the rectum. Wrong plumbing, die never mind but have to have maid by my side for the rest of my life. Now I bark at her when it suits me. When I am in that state because of the poor plumbing job by the nincompoop, it's her turn to bark at me!

Guess something should be done. The question is not whether the doctor is tough enough but is he in the best state to take care of the patient. I am all for change. I am not a doc but I have heard bad stories. I also have friends that sleep behind the wheels after their calls. While I admire your resilience it is not in the best interest of patients to have a tired doctor.

dr oz bloke said:"Should doctors who had not slept in 24 hours be treating patients at all?

Answer that question objectively and directly. No buts, no manpower explanations. Just answer logically whether that should be taking place."

I take your point. But because I love to bone pick, I'll post a reply.

Of course that should not be taking place. Are you suggesting that all doctors who have not slept in 24 hours announce their tiredness, get up and leave? Clearly that would not be feasible, and I daresay the fault lies in the system and not "stupid" doctors.

Your definition of stupidity assumes a few things, all of which can't be assumed:

1. That all doctors are selfless. (which is sad you can't assume, but this is reality.)

2. That tiredness which will lead you to kill someone, and tiredness that will not cause you to kill someone is independent and exclusive (furthermore, I daresay that after a certain number of hours, even the simple fact of whether one is tired or not is difficult to differentiate)

3. That doctors after working for hours on end have a clear idea of the circle in the Venn diagram in which their mental exhaustion lies

Furthermore, responsibility is two-fold: not only do you need to know when you'd be so tired as to kill patients and should stop, you also can't be skiving off work. You can't just leave, without having someone else pile your workload on top of his own.

So the "stupid" doctors have made their point. The sheer number of mistakes made and people killed. I'm sure no one meant for all that to happen. Surely the basic fact of stopping when tired isn't new and is in the mind of any moron anyhow. Are you suggesting that we still rely on these doctors to know when to stop?

Uglybaldie's mentality is a common one -"I slaved so you must slave too.. *muahahahaha*" However, the real stupidity lies in such a mentality, in the face of such stark statistics. Letting more patients die so that young doctors can suffer is the best proposal I've heard.

At the end of the day, those in a vocation that is integral to saving lives should be better designed. And that is my point.

Most studies rind that italics degrade redability, and I'm sure you'll agree that this is true, particularly on the internet, with a small font. There is a -reason- that people quote with italics.

I've been saved by this because i'm using a huge monitor, and a browser which can scale all text (opera, but firefox will also do.)--"One patient's death in the hospital has never been termed a disaster by the media."

I think this is the one of the greatest tragedies of all.

I think it is clear that measures should be put into place which reduce the number of hours doctors are expected to work, and to allow them to leave (almost) immediately, post-call. I think this is actually Singapore government policy, insofar as they have increased the number of medical students consistently over the last couple of years.

It is also stupid to claim that working 24 hours in no big deal. Sure - everyone does it now and again, and perhaps some unfortunate souls have had to work for 60 hours nonstop - but there's no reason to perpetuate stupidty.

Industrial action by doctors in Israel seems to be good for their patients' health. Death rates have dropped considerably in most of the country since physicians in public hospitals implemented a programme of sanctions three months ago, according to a survey of burial societies.

.

In the absence of official figures, the Jerusalem Post surveyed non-profit making Jewish burial societies, which perform funerals for the vast majority of Israelis, to find out whether the industrial action was affecting deaths in the country.

"The number of funerals we have performed has fallen drastically," said Hananya Shahor, the veteran director of Jerusalem's Kehilat Yerushalayim burial society. "This month, there were only 93 funerals compared with 153 in May 1999, 133 in the same month in 1998, and 139 in May 1997," he said. The society handles 55% of all deaths in the Jerusalem metropolitan area. Last April, there were only 130 deaths compared with 150 or more in previous Aprils. "I can't explain why," said Mr Shahor.

"I think this is actually Singapore government policy, insofar as they have increased the number of medical students consistently over the last couple of years."

My suspicion is that regardless of the number of junior doctors you have, workload will expand to fill their available time. The average length of stay in hospitals have shortened considerably over the past ten years, but instead of having more empty beds what we are seeing is a higher turnover.

Remember the rise in A&E attendance at AH after it was announced that they had the shortest waiting time.

What we need to do is to limit the demand, not increase the supply.

The system must have enough moral courage to say: no you can't dump your father here for the weekend while you go on a holiday because he is NOT sick.

or

No I don't care if you have to take leave to look after your mother, she can't stay here for another day because she is already well and there are people cooped up in the A&E who need treatment and her bed.

First and foremost, I totally agree that increasing manpower will not solve the problem.

I have seen departments get up to 50% more junior doctors and then after 2 years they say they are short (again). Why? Like you said, new projects and work is created for the "fat" in manpower. Best example is getting MOs to do presentations for M&Ms with power point etc. Do journal club presentations. Running more clinics. Writing research papers for scientific meetings and international peer reviewed journal submission.

As for the hospital demand....

The best example was during the SARS period. I recall doing calls at SGH during that period and the hospital walkways were deserted. Admission were very low.

We all wondered where had the patients gone? Were there more deaths during that period? Who knows? But if there wasn't (and it was not reported as so) then clearly the demand should not be as high.